FEDERAL CT - BUILDING INSPECTION 0 E)cc -0 kt�02(� �03�
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AP CTIOdAL SERVICES The Commonwealth of MdssalfiJa AL SERVICE:
Department of Public SafetyW '
MAR 32 A 3 58 = Massachusetts state Building Code(780 MAR 32 A 4t 0l
Building Permit Application for any Building other than a r'I wo Family Dwelling
N (This Section For Official Use Only)
Building Permit Number: Date Applied: - Building Official: -
1 'SECIION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Ct SQ c.�, , lr k 19 19'70 Rtpt S G r eevk LNa V S
No.and Street City/Town Zip Code Name of Building(if applicable)
$ECT10N2•.PROPOSED WORK
\� Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No J0
Ism Independent Structural Engineering Peer Revi r ed7 pYes ❑ No.
Brief Description of Proposed Work 10 l TC
.�tE .0 oR�g�
' SECTION 3:COMPLETE THIS:S ON IF EXISTING BUILDING.UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluatian is enclosed(See 780 CUR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4.BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION S:USE GROUP(Cheek as applicable). - -
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ I H: lligh Hamrd H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
- SECTION 6i CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB13 IIA ❑ IIB ❑ MA ❑ HMO IV ❑ VA ❑ VB ❑
- - SECTION 7 SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes No ❑
SECTION S:CONTENT'OF CERTIFICATE OF OCCUPANCY. - -
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
�;6 CMl�A—
-:SECTION 9:'PROPERTY OWNER AUTHORIZATION.,..
Name and Address of Property Owner
P E, M, I61 Essex m r7 0tl?O
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
ate move he gSoo
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu:ft.of enclosed space and/or not under Comtruction Control then check here O and skip Section 10.1
10.1-Registered Professional Responsible for Construction Control - -
Name(Registrant) - Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
102 General Contractor -
AV,%eM��a� S`f«�l'r- A- Towe Ca:; Z4c .
Company Name
NTe- S L. �3ro �/ C,S OS433ya
Name of Person Responsible for G6n§truction License No. and Type if Applicable
373 �SS �X S I t S61cw1f w► � Uf°I? p
Street Address City/Town State Zip
Q_lL- 15 L( _$- 87 I y 4 6 r o t[f�� f G. a w+e tce� slti�plc, vie t
Telephone No.(business) Telephone No. cell email address
'SECI710N 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.a 152:§25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? YesA No O
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2 Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ -
Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
'- -SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT `
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding. 0
f e-%,t ,�cV <S'a Q tic---S— -,c 4t4-2 Llsi&I IS
Please rint and sign name Title Telephone No. Date
L Wr `�1 M� O1al_>O
Street Address City/Town /State Zip
Municipal In to fill out this section upon application approval: LI 6-
- - - -Name Date._
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block# and Lot#for locations for which a street address is not
available)
No.and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other(if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107.The
checklist below is a compilation of the documents that may be required for this.The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other
10 Surveyed Site Plan(Utilities;,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Pro am
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation,Insurance
19 Hazardous Material Mitigation Documentation
20 Other S
21 Other S
22 Other S
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci /Town State Zi Discipline Expiration Date
%I1 x' OF S.U.Mv;, XLkss kc: usEi vs
BL'IIDNG DEP,,R11tmN''T
�i 130 WASH NGTON STREET,3° FLoOR
in m - �e ncne
ki7of ,�r959,
FAX(978) 740.9846
KIMBERL.EY DRISCOLL
MAYOR THobtAs ST.Pwatm
DIRECTOR OF PL'Bttc PROPER'IY/BUUMNG CON IISSIONER
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition,of the State Building Code, 780 CMR section i 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
i }`t +z
(name of facility)
(address of facility)
signature of permit appli ant
Y/oj �S
date
dchrisa(LcLc
. o
Salem Histotical Commission
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
El Reconstruction ❑ Alteration
❑ Demolition ❑ Punting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: ` Federal Court(E apes Mansion Greenhouse)
Name of Record Owner: Peabody Essox Museum
Description of Work Proposed:
Restoration of greenhouse. No changes will be made to the design, materials, or color.
Non-applicability due to work being in-kind repair and/or replacement.
Dated: June 2, 2014 SALEM HISTORICAL COMMISSION
B�
The homeowner has the option not to commence the work(unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals)prior to commencing work.
i CITY OF SM EN1, 2UNSSACHUSETTS
e • Bt;MIXNGDEPARTJMNT
r `f 120 W ASHINGTON STREET,3'FLOOR
'.'SM (978)745=-9595
FAX(978)740-9M
Kl\[BERLEY DRISCOLL
,MAYOR THOMAs Sr.PmR=
DIRECtOR OF PUBLIC PROPERTY/BVILDING COMMISSIONER
Workers'Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information (�f Please Print Le 'biv
Name(Busimxm OrganiratioNtndividual): ��4b tGd h JTe '< A-Tb1��'�
Address: 3 7 3 F s5 X S f r e e f'
City/State/Zip:. SO,`e 1M, ` q A- 0 I of 7 U Phone f#: 9 7`- ^ 7 c! t4—
Are you an employer?Check the appropriate bolt:
1.j5d am a employer with t 4. ❑ 1 am a general contractor and I Type project required):
employees(full and/or par.=aerie).• have hired the sub-comractors 6_ ❑New construction
2.❑ 1 am a sole proprietor ar partner- listed on the attached sheet t 7. ❑Remodeling I
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. I 9. ❑Building addition
(No workers'comp, insurance 5. El w.a are a corporation and its
required.) officers have exercised their MCI Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL i 1.0 Plumbing repairs or additions I
myself.(No workers'camp. C. 152,§1(4),and we have no 12,❑Roof repairs
insurance required.]f employers.(No workers' I 13.❑Other
comp.insurance required.]
'Any applicant that checks box it l mutt also till ewt the section below showing their woken•cwnpennstion policy infoatatitm.
t 1 hsmeuwren who submit this affidavit indicating They me doing all work and Ihm hire outside conttactots must submit anew affidavit indicating such.
=Cemaae:ton chat cheek this box meet athcltetl an xWitiwel shsH showing the name of it—:ubcorttramrs--:Mr warkae'anap.policy inforattoa.
I um as eniplayer that is pravidbig worker'compensa Lion insurance for my employees. Below Is the policy and fob she
information. T� e- a V�/1 r
Insurance CompanyVame: o ' I /� 1��. y
Policy#or Self-ins.Lic.M. q 6 0 1 r 7 nS^� lJ� — Expiration Date:. 4 1 b, I 6 `
Job Site Address: Ftecf¢�''o�� C,OV1f `, Sg1�yv).�/'VI �. Df�'�
City/State/Zip: L)
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of die DIA for insurance coverage verification.
I do hereby eerdfy under the a! nd penahies of perjury that the information provided above is true and correct
Si•nal re; �. tr `r
PhoneaY: '7)D - � `4 -� � f
Oj:'ciaf use an!): Do nat write!n*his area,to be completed by city or town ofj-rcial
City or Town: PermidUcense#
Issuing Authority(circle one):
1.Board of lleaith,2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other._
Contact Person: _ Phone#